Richard M. Fairbanks School of Public Health Theses and Dissertations
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Item Leadership Developments for Effective Implementation of Universal Health Coverage in North West Province of South Africa(2025-09) Kuwane, Bulelani; Babich, Suzanne; Czabanowska, Katarzyna; Setswe, GeoffreyThe research explored how best to develop leadership competencies amongst health leaders to support successful implementation of Universal Health Coverage (UHC) in the North West Province of South Africa (SA). SA will implement UHC through the National Health Insurance (NHI). The aim of the research study was to explore how best can leadership competencies be developed in the public health workforce to effectively implement UHC. The objectives were, a) Describe current health leadership competencies needed to advance the implementation of Universal Health Coverage in South Africa. b) Identify barriers and facilitators to health leadership in South Africa. c) Develop an effective leadership development model for the implementation of Universal Health Coverage in the North West province of South Africa. The research study was qualitative study using a non-experimental, descriptive design methodology. The data were gathered through key informant interviews with healthcare leaders using MS Teams. Interviews were recorded and transcribed. Data were analysed by looking at themes and patterns using NVivo system. The findings of the research showed that strategic vision and planning, openness to mentorship and learning, effective decision-making, reassurance and confidence building, vulnerability and emotional intelligence, collaborative leadership, advocacy and influencing, budgeting and resource allocation. accountability in financial practices are important leadership competencies for implementation of UHC. The research showed that mentorship, peer support, international partnerships and training programs are facilitators of leadership development. Structured leadership programs, continuous professional development, advocacy for leadership support and de-politicising appointments were recommended strategies for leadership development. This study emphasized the critical need for resilient and flexible leadership in response to evolving problems in SA's healthcare sector. There is an urgent demand for leaders in health to be not only technically sound but also emotionally intelligent, strategically savvy, and operationally capable enough to thrive in complex policy and resource environments.Item How Can a CRO-Specific Leadership Framework be Developed to Enhance the Effectiveness and Efficiency of CRO Leaders in Managing Clinical Trials?(2025-11) Li, Jianrong; Nan, Hongmei; Han, Jiali; Anderson, Randy L.The high cost of medicine in the U.S. presents a critical public health challenge, limiting the accessibility and affordability of essential treatments. While many factors influence drug pricing, reducing development costs through efficient CRO operations and effective leadership can support more competitive pricing and improved access. This project aimed to establish a CRO-specific Leadership Framework by conducting interviews with seasoned CRO leaders and leaders from Pharma and Biotech companies to capture insights and best practices. A qualitative research approach was adopted to explore the traits, expertise, and characteristics that define successful CRO leadership. Semi-structured interviews were conducted, recorded, transcribed, and analyzed using thematic analysis with Quirkos software. The study resulted in the development of a CRO-specific Leadership Framework that identifies six REAJIA traits - Resilience, Empathy, Adaptability, Judgment, Integrity, and Acumen - mapped to externally observable leadership behaviors. In addition, the “Leadership Wheel” was created to illustrate how these traits interconnect dynamically to drive effectiveness in CRO environments. Together, these tools provide a structured approach for understanding and cultivating leadership that balances operational efficiency, sponsor satisfaction, and team performance. This project contributes to both academic and practical discussions on leadership in clinical research. The framework and leadership wheel offer CROs and sponsors a foundation for leadership assessment, development, and evaluation. By clarifying the traits and behaviors most critical in CRO contexts, the study highlights leadership’s central role in improving efficiency, strengthening collaboration, and supporting more sustainable drug development practices. Future research should focus on quantitatively validating the framework, testing cross-cultural applicability, and incorporating emerging competencies such as digital leadership to reflect innovations in clinical trials.Item Evaluating Multi-Cancer Early Detection (MCED) in Medicare: Cost-Effectiveness and Policy Pathways for Pancreatic Cancer(2025-12) Raygoza, Adrian Ignacio; Han, Jiali; Reina Ortiz, Miguel; Reed, Steven B.Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal cancers. Most patients enter the clinical pathway at an advanced stage, long after symptoms have appeared, which limits treatment options and survival. Multi-Cancer Early Detection (MCED) tests that examine methylation patterns in circulating cell-free DNA offer a possible route toward earlier, more actionable diagnoses. Even with that promise, questions remain about the true economic value of these tests and the feasibility of Medicare coverage for the populations that may need them most. This dissertation used a convergent parallel mixed-methods design to examine these questions. The quantitative analysis relied on a patient-level microsimulation built from nine confirmed Stage II and III PDAC cases, each supported by real-world billing data. The model was expanded through 30,000 Monte Carlo replications to test stability and ranges of possible outcomes. The average cost per patient was $177,691. When applied to the 67,440 projected incident PDAC cases in 2025, this produced a conservative lower-bound estimate of about $12.0 billion in national direct medical spending. Stage-weighted modeling showed that most of these costs come from distant-stage disease, which accounts for more than three-quarters of total spending. When adjusted to the share of Medicare beneficiaries, the estimated Medicare-attributable spending ranged from $7.2 to $9.6 billion each year. The qualitative analysis examined eight elite interviews with congressional staff conducted between February and July 2025. By the eighth interview, thematic saturation had been reached, producing 21 themes across fiscal, clinical, and policy areas. Staff from both parties raised persistent concerns about Medicare solvency and emphasized the need for strong fiscal safeguards in any new coverage pathway. PDAC was viewed as a compelling application for MCED because of its severity, limited early detection options, and the high costs associated with late-stage care. Across offices, Coverage with Evidence Development (CED) emerged as a feasible policy pathway, supported by constituent stories and earlier precedents in colorectal screening tools. Convergent integration of the two strands demonstrated how the cost modeling and policy perspectives align. Both strands identified Stage III PDAC as a major source of economic and clinical burden, and congressional staff viewed feasibility through the lens of Medicare solvency and patient access. CED appeared as a shared mechanism that could balance early innovation with careful fiscal oversight. Bringing together health economics and elite interviewing illustrated how policy feasibility can be assessed in a practical way. The findings suggest that MCED for PDAC may be both economically and politically feasible when directed toward high-risk populations within a Medicare CED pathway, creating an opportunity to support earlier detection in a cancer that remains one of the most urgent challenges.Item Analyzing the Association of COVID-19 Vaccination with Changes Among Individuals with Diabetes and Obesity: A Retrospective Cohort Analysis Among Indianapolis Metropolitan Residents(2025-12) Hanley, Shane M.; Han, Jiali; Dixon, Brian E.; Duszynski, Thomas J.; Grannis, ShaunIntroduction: The COVID-19 pandemic was detrimental in a multitude of aspects of health. One specific area of research that was touched on but not to a greater extent was the impact of the COVID-19 pandemic on the clinical visits for those with other comorbidities. In relation to this dissertation, the focus is to highlight the impact COVID-19 vaccines had on A1C levels and weight before and after vaccine availability. Methods: A retrospective cohort was designed by selecting residents from Indianapolis metropolitan hospitals who were diagnosed with diabetes or obesity prior to January of 2019. The study period began in 2019 right before the COVID-19 pandemic and ended in December of 2022. Descriptive statistics were computed to display the difference in proportions of all covariates by vaccine status. Multiple logistic regression was conducted to test for the potential association between those who were vaccinated and lower on average AIC level or average weight in kilograms by end of study compared to those not vaccinated. Separate confounding and interaction testing were conducted as well on all other covariates individually with vaccine status. Results: Those that were not vaccinated had a 0.11 greater AIC level by end of study compared to those that were vaccinated and while controlling for all other covariates was still 0.29 with the largest statistically significant confounder being diabetes at 0.30. Those that were not vaccinated had a 4.04 kilograms greater average weight by end of study compared to those that were vaccinated and while controlling for all other covariates was still 0.92 kilograms heavier among the non-diabetic group. Those that were not vaccinated had a 6.36-kilogram greater average weight by end of study compared to those that were vaccinated and while controlling for all other covariates was still 3.40 kilograms heavier among the diabetic group. Conclusion: This study helps quantify the relationship between COVID vaccine status and A1C/weight management. More research is warranted to further observe these health outcomes beyond the height of the pandemic.Item Studies Examining Maternal Vaccination Decisions and Influenza Burden in U.S. Infants Ages 0-5 Months(2025-11) Albertin, Christina Susanne; Dixon, Brian; Duszynski, Thomas; Zimet, Greg; Turman, Jack E.Introduction Pregnant women and young infants are particularly vulnerable to respiratory viral infections, but infants aged 0-5 months cannot receive COVID-19 and influenza vaccines, making maternal vaccination a key prevention strategy. We examined changes in rates of maternal COVID-19 and influenza vaccination, influenza-associated hospitalization burden and characteristics of influenza positive infants aged 0-5 months by acute care setting. Methods Data from two health systems and a surveillance network were analyzed. Study 1 examined COVID-19 and influenza vaccination patterns between two temporal cohorts of pregnant women (2021-2023, n=5,949). Study 2 compared characteristics of influenza-positive and influenza-negative hospitalized infants aged 0-5 months and calculated an influenza hospitalization rate for this age group from 2016-2020 (n=2,605). Study 3 compared infants with laboratory-confirmed influenza discharged from the emergency department versus hospitalized (n=210). Results In Study 1, COVID-19 vaccinations fell substantially between the two cohorts (62% to 26%), while influenza vaccination showed a lesser decline (52% vs 48%). Those receiving neither vaccine increased (26% to 44%). Study 2 found influenza-positive infants had less severe illness than influenza negative infants, 79% of whom tested positive for other viral pathogens. The calculated influenza hospitalization rate was 129.5 per 100,000 infants. Study 3 identified younger age and underlying condition as associated with hospitalization (aOR 4.37, 95% CI 2.11-9.06, aOR 6.29, 95% CI 2.34-16.86). Public insurance and higher maternal education had lower odds (aOR 0.12, 95% CI 0.04-0.34), aOR 0.36, 95% CI 0.14-0.91). Conclusion Our calculated influenza hospitalization rate (2016-2020) was significantly lower than historical estimates from the 2000s, coinciding temporally with increased national maternal influenza vaccination coverage. Our analysis of influenza among infants aged 0-5 months demonstrated that influenza comprised a small proportion of acute respiratory illness hospitalizations. Maternal vaccination patterns revealed declines in uptake of both vaccines between 2021-2023, with COVID-19 vaccination showing the steepest decrease. Considering recent national declines in maternal influenza vaccination, our findings underscore the importance of developing targeted interventions to improve maternal vaccination coverage and sustain reduced influenza hospitalization burden in this age group.Item Medicaid Continuous Eligibility and its Associations with Administrative Costs, Unmet Needs, and Health Service Utilization(2025-10) Tran, Yvette Ho; Blackburn, Justin; Holmes, Ann M.; Vest, Joshua R.; McFarlane, Timothy D.Medicaid acts as a vital safety net in the United States—providing health insurance for households with limited income, seniors needing long-term care services, and persons with disabilities. However, income fluctuations and unsuccessful Medicaid renewals result in transient lapses in coverage for some enrollees, otherwise known as churn. Prior studies have estimated that around eight percent of enrollees experience churn within a year. Enrollees experiencing churn may be more likely to delay or forgo preventive care, potentially leading to adverse health outcomes and higher healthcare costs downstream. Policies such as implementing ex parte renewals or reducing the number of eligibility checks conducted each year have helped to reduce, but not eliminate, churn. In March of 2020, the United States Congress passed the Families First Coronavirus Response Act, which introduced maintenance of effort (MOE) requirements in exchange for enhanced federal funding to states. To comply with MOE requirements, states ensured enrollees had continuous eligibility throughout the public health emergency period, which spanned March 2020 through March 2023, regardless of changes in financial circumstances. This policy temporarily eliminated almost all churn and contributed to record high Medicaid enrollment, but its consequences for administrative cost, unmet healthcare needs, and service utilization are unclear. The purpose of this dissertation is to assess the relationship between continuous eligibility policy and 1) administrative costs; 2) unmet medical, dental, and prescription medication needs; and 3) health service utilization. This dissertation includes three studies: 1) a pre-post analysis of state-year panel data that assesses trends in overall, per-enrollee and per capita administrative spending; 2) a difference-in-difference with inverse probability weights analysis that examines the relationship between churn and unmet medical, dental, and prescription medicine needs; and 3) a comparative interrupted time series study that compares changes in well-child, preventive dental, office-based, emergency department, and hospital encounters by history of churn. With Medicaid consuming about eight percent of federal and 30 percent of state budgets, respectively, policymakers have and will consider Medicaid financing reform, benefits redesign, and innovations in eligibility and renewal policies. Evidence from this dissertation will help inform policymakers about the tradeoffs of various decisions and priorities.Item Barriers to Trust in the Utilization of Health-Related Social Needs Data from the Electronic Health Record(2025-08) Allen, Katie Sue; Vest, Joshua R.; Blackburn, Justin; Dixon, Brian; Yeager, ValerieAddressing health-related social needs (HRSN)—such as food insecurity, housing instability, transportation barriers, and financial strain—is increasingly recognized as essential to achieving equitable health outcomes. These factors play a critical role in shaping patients’ health risks, care access, and health outcomes. Consequently, understanding and addressing HRSN is vital to both clinical decision-making and population health management. The electronic health record (EHR) holds promise as a tool for the systematic collection and use of HRSN data. However, current practices are marked by inconsistencies and limited adoption of structured coding systems. Highquality, standardized data are critical for the meaningful application of HRSN information, yet multiple barriers hinder collection. These challenges are not solely technical. Patients may be reluctant to disclose sensitive social information, and clinicians may feel discomfort or uncertainty about asking, recording, or acting on such data. These attitudinal and structural obstacles introduce the potential for bias in EHRderived data, which may compromise the fairness and effectiveness of downstream applications. If unaddressed, these limitations may undermine trust in the utility and accuracy of EHR-based social factors data. This dissertation investigates the structural and attitudinal factors that influence trust in EHR-derived HRSN data, with a focus on data quality, documentation practices, and clinician perspectives. First, it evaluates the robustness of EHR-based HRSN data by comparing prevalence estimates derived from structured fields with external community benchmarks. Discrepancies highlight areas where under-documentation or misrepresentation may occur. Second, the study examines demographic and system-level characteristics associated with whether patients’ social needs are captured in the EHR, identifying patterns that may reflect disparities in documentation. Third, semi-structured interviews with clinicians provide qualitative insight into their experiences documenting HRSN, their trust in the data’s accuracy, and their perceptions of its role in clinical care. Together, these mixed-methods investigations offer a comprehensive understanding of the barriers and facilitators to trustworthy and equitable use of HRSN data within EHRs. Findings will inform future strategies to strengthen data quality, enhance clinician engagement, and ensure that EHR-derived social factors data can be reliably leveraged to support health equity and improved patient outcomes.Item Exploring Awareness of Implicit Bias Within New Zealand's Chronic Pain Management Healthcare Workforce: Is Current Regulation Serving Them Best?(2025-06) Bowering, Lara Jane; Archer, Sarah; Yeager, Valerie A.; Chadwick, MartinObjective: To explore the knowledge and beliefs about implicit bias in chronic pain management healthcare practitioners in New Zealand and analyse the current Regulatory Authority competence documents and guidelines, regarding the topic of implicit bias. Additionally, provide recommendations for Regulatory Authorities regarding implicit bias messaging, training and competence framework implementation. Setting: Interviews were carried out with members of both public and private Chronic Pain Management Services across New Zealand from February 2025 to May 2025. Relevant Regulatory Authority documents were analysed during February 2025 to March 2025. Study Design: The research study was an exploratory mixed-methods approach. The qualitative portion involved semi-structured healthcare practitioner interviews. The Regulatory Authority documents were analysed independently for words and narrative. Data was then combined and analysed to obtain detailed insights for making recommendations. Data collection: Microsoft teams was used to audio record and transcribe interviews with 15 healthcare practitioners. Interviews were coded using NVivo to identify themes. Regulatory Authority documents were accessed online and explored manually as well as word searched electronically. Principal Findings: Several themes emerged from participant interviews regarding sources of perceived knowledge, associated emotions and actions and the perceived effects of implicit bias. A varied understanding of the concept exists within the cohort and few healthcare practitioners get their information about implicit bias from their Regulatory Authority: An impression of lack of agency regarding change was observed in all interviews. Even though competence and code of ethics documents are extensive, they lack definition, measurement or suggested training options for their members regarding implicit bias. Discussion: This study is the first in New Zealand to qualitatively explore the beliefs and knowledge of any healthcare workforce cohort about implicit bias. Current levels of knowledge are being impacted by a lack of guidance and definition from Regulatory Authorities as well as overall support and access to relevant evidence-based training options. Conclusion: Simple changes within Regulatory Authority documentation, as well as cross-authority collaboration, could positively impact levels of implicit bias knowledge alongside training uptake. These easily implemented changes are needed to promote movement towards the healthcare service goal of patient-centred care.Item Exploring the Intersection of Substance Use, Mental Health, and Mortality Among the U.S. Youth: A Comprehensive Analysis of Trends, Associations and Interventions(2025-07) Jain, Nitika; Han, Jiali; Nan, Hongmei; Monahan, Patrick O.; Harle, ChrisMy PhD journey has been long and eventful, filled with various personal milestones and challenges. I experienced the joy of welcoming my daughter into the world, changing two jobs, and relocating across two homes and states while also enduring the deep sorrow of losing my beloved grandfather. Despite moments of self-doubt and instances where I almost felt like giving up, this journey has strengthened my wisdom and resilience. Through it all, one constant remained, my passion for driving meaningful change in the field of mental health and substance use, supported by the unwavering encouragement of my community, which kept me moving forward, one small step at a time. As they say, great ideas are not the work of one, but the product of a well-knit supportive community. So, with that in mind, I dedicate my dissertation to the following: 1. My loving husband and beautiful daughter, who have been my unshakable pillars of strength and support throughout the journey. 2. My parents, in-laws, and extended family in India, who instilled in me values of integrity, honesty, and humility, virtues that are reflected throughout my dissertation. 3. My late grandfather, whose constant encouragement to stay curious, fueled my passion. He often asked me “When will you finish your PhD” and “I can’t wait to read your dissertation”. So, Daddy, this one is for you! 4. My incredible friends whose words of motivation kept me going whenever I thought of giving up, especially Dr. Rizwana Biviji, my dear friend and IU PhD program alumna, who has been my moral support and inspiration throughout. 5. My mentors and teachers in India, Mauritius, and the U.S., who instilled in me the importance of questioning, learning, and following the path of science and facts. 6. Last but not least, all those young promising individuals who tragically lost their lives to the menace of substance use and mental illness. Their struggles and the lessons learned from their short but impactful lives inspire us to strive for positive change in communities.Item Improving Supply Chain Systems for the Efficient Monitoring of Medical Countermeasures During Public Health Emergencies in the Federal Capital Territory, Nigeria: Recommendations for Systems and Policy Improvement(2025-07) Aminu-Alhaji, Asmau; Babich, Suzanne Marie; Joseph, Gbenga Solomon; Duszynski, Thomas J.During the COVID-19 pandemic, the Nigeria Center for Disease Control and Prevention (NCDC) encountered significant challenges in maintaining visibility over medical countermeasures (MCM) deployed to sub-national levels. A nonexperimental, descriptive research design using semi-structured key informant interviews (KII) was employed to gather qualitative data on what factors contributed to poor visibility of deployed MCMs in the Federal Capital Territory (FCT), Nigeria. This research focused on the FCT but reflected a broader nationwide challenge. Key informant interviews were conducted, and data analysed employing deductive and inductive coding to identify main themes. Secondary data were obtained from literature reviews. Findings showed NCDC's logistics and supply chain system was unprepared for the COVID-19 pandemic, underscoring the need for improved emergency preparedness and readiness. An MCM strategic plan existed but was not fully developed or operationalized at the onset of the pandemic. NCDC relied on the FCT’s Department of Public Health (DPH) for its supply chain management, despite the Department of Pharmaceutical Services (DPS) being responsible for FCT's established public health supply chain system. NCDC and the FCT had an insufficient workforce with limited experience in managing a large-scale outbreak response. The public health workforce was insufficient with noticeable gaps in training that impacted overall effective management. NCDC’s electronic logistics management information system at the time of the pandemic was not integrated with other existing reporting systems and did not support end-to-end transactions. Efforts to automate the system for end-to-end visibility were unsuccessful forcing NCDC to resort to manual operations. The absence of a national reporting tool and standardized guidelines further hindered effective tracking and reporting of MCMs. Unlike other government agencies, such as the National Primary Health Care Development Agency (NPHCDA), which maintained visibility and control over vaccine distribution through established networks and collaboration, NCDC did not leverage existing resources and structures. Strengthening coordination across agencies, clarifying roles, investing in workforce capacity, and implementing integrated digital systems should be prioritized within revised policy frameworks to ensure better preparedness and visibility in future public health emergencies.